For Australian Medicare (MBS), common codes are Item 45617 for medically necessary upper eyelid reduction (due to vision impairment, inflammation, etc.) and Item 45620 for lower eyelid issues like fat herniation or ectropion, requiring specific clinical justification for a rebate, as cosmetic blepharoplasty isn't covered. In the U.S., CPT codes like 15823 might apply, with specific diagnostic (ICD-10) codes detailing medical necessity, per the Centers for Medicare & Medicaid Services.
Medicare will cover a blepharoplasty after you have a visual field test by your ophthalmologist to prove that your lids impair your vision. I would recommend you find an ophthalmologist who is also a facial plastic surgeon.
Item 45617 | Medicare Benefits Schedule.
Key takeaways
Medicare does not cover surgery for sagging eyelids if it is for cosmetic reasons only. Medicare Part B or Medicare Advantage may cover the costs of blepharoplasty if deemed medically necessary to improve eye function due to ptosis (sagging eyelids).
Insurance coverage for eyelid surgery, such as blepharoplasty, hinges on demonstrating that the procedure is medically necessary due to functional impairment, not purely cosmetic reasons. To qualify, patients must provide detailed documentation from a qualified ophthalmic or medical professional.
Good candidates for eyelid surgery include:
Upper eyelid blepharoplasty or blepharoptosis repair is considered MEDICALLY NECESSARY for ANY of the following conditions: 1. Difficulty tolerating a prosthesis in an anophthalmic socket; OR 2. Repair of a functional defect caused by trauma, tumor or surgery; OR 3. Periorbital sequelae of thyroid disease; OR 4.
One of the most common questions patients have is, “Does insurance cover blepharoplasty?” The answer depends on whether the procedure is medically necessary or cosmetic. Medically necessary blepharoplasty, which improves vision or addresses functional issues, is more likely to be covered by insurance.
ICD-10 code H02. 3 for Blepharochalasis is a medical classification as listed by WHO under the range - Diseases of the eye and adnexa .
Six Signs You Might Be Ready for Eyelid Surgery
Blepharoplasty costs in Australia typically range from $3,000 to over $20,000, varying greatly based on whether it's cosmetic or functional (vision-improving), the specific surgeon, location, and if it's upper, lower, or both eyelids; functional cases may receive Medicare/private health rebates, significantly lowering out-of-pocket expenses. Cosmetic procedures aren't rebated, so expect higher out-of-pocket costs, especially for complex cases, while simpler procedures under local anaesthetic might be cheaper.
No, Original Medicare doesn't cover routine eye exams , also called “eye refractions,” for eyeglasses or contact lenses. However, a simple vision test is included in your “Welcome to Medicare” preventive visit. The visit is covered by Medicare Part B and offered only once within the first year of enrolling in Part B.
Upper eyelid reduction surgery - Changes to MBS item 45617.
On average, patients can expect a Blepharoplasty to cost around $3,200. However, if the puffiness or drooping is inhibiting your field of vision, the surgery may be deemed medically necessary.
A visual field defect is confirmed by an optometrist or ophthalmologist. Your eyelid skin folds onto itself, causing inflammation known intertriginous skin inflammation. You have post-traumatic scarring. You have facial nerve palsy.
In most cases, this means that your eyelids must be obstructing your vision or causing significant discomfort. To prove this, you will need documentation from a specialist—such as an ophthalmologist or plastic surgeon—stating that blepharoplasty is necessary for medical reasons.
One can qualify for eyelid surgery, covered by medical insurance, if it is deemed medically necessary. The main reason cited is impaired vision is caused by excess upper eyelid skin which can make everyday activities such as driving, reading and using telecommunication devices much more hazardous.
Cosmetic eyelid surgery is not covered by Medicare. Eligibility for coverage begins at age 65, but younger individuals with certain disabilities may qualify. The average cost of upper blepharoplasty is $3,359 without insurance. 2025 Medicare Part B deductible is set at $257.
The visual field test is performed to assess the visual fields at rest, and after taping the redundant eyelid skin up, to mimic the effects of surgery. Most insurance companies require at least a 30% improvement in the visual fields with taping in order to approve this procedure.
Medicare will only cover plastic surgery procedures that are deemed medically necessary. These typically include reconstructive surgeries following accidents, burns, or cancer treatments, as well as procedures to alleviate congenital abnormalities or increase bodily functions.
Blepharoplasty cons include common temporary issues like swelling, bruising, and dry eyes, but also potential risks such as infection, scarring, and vision changes; more serious, though rarer, complications involve difficulty closing eyes (lagophthalmos), ectropion (eyelid turning out), ptosis (droopy lid), or even blindness, often stemming from removing too much skin or fat, leading to an unnatural or sunken look, and highlighting the need for a skilled surgeon.
WHAT ARE THE NEWEST BLEPHAROPLASTY TECHNIQUES? The most current trends in blepharoplasty tend to emphasize minimally-invasive techniques involving fat transfer or supplementation rather than simply making incisions to remove existing tissue.
You may have to add some supplements to your diet like the aforementioned vitamin C, vitamin K, vitamin E, vitamin D, vitamin B12, and iron. And perhaps stack up on topical creams that boast said nutrients. Or just change your diet to include healthier food rich in vitamin and minerals.
Physical Exam and Documentation
A physical examination is an important part of determining whether blepharoplasty is medically necessary. During the exam, the surgeon assesses how much excess skin is present, whether it rests on the eyelashes, and how it affects vision.